Financial Policy

Please correct the errors described below.

We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.

**Care Credit and Lending Club Financing options are subject to amount financed and credit approval.

Adult Patients and Minors Accompanied by Adult

Adult patients and adults accompanying a minor patient are responsible for payment at the time of service. Special financial arrangements can be made with the business office before treatment begins.

Unaccompanied Minors

Proposed treatment sometimes changes during the procedure due to the needs of the tooth. To assure quality care of the patient, it may be necessary to proceed without the consent of the parent or the guardian if they have left the facility. The parent or guardian is responsible for payment the day of treatment, and will be financially responsible for the necessary changes in minor’s treatment.

Insurance Is a Contract Between You, Your Employer, and Your Insurance Company

We are not a contracted provider with any insurance companies.
Dental insurance is playing an ever increasing role in assisting people obtain dental treatment. We feel strongly that our patients deserve the best dental care we can provide and in an effort to maintain a high quality of care, we would like to share some important facts with you regarding dental insurance.

We consider our relationship with you to be of primary importance and our recommendations will always be based on what we believe is the very best treatment for you, regardless of insurance coverage. As the patient, it is your responsibility to communicate with your insurance company and your employer. We are happy to assist in any way possible to maximize your dental insurance benefits, even though we have no relationship or responsibility to your insurance company.

If your insurance company has not paid their portion within 45 days, the full balance will be your responsibility. You will have an additional 15 days to pay the balance.

FACT 1: Dental insurance is an aid, it is not meant to “Pay-All”.

FACT 2: Many plans tell the insured that they will be covered “up to 80%” or “up to 100%”. In spite of what you are told, we’ve found that many plans cover 40% to 50% of any average fee. Some plans pay more, some less. The amount your plan pays is determined by the contribution you and your employer make to your dental plan. It is your responsibility to advise us of your insurance coverage and restrictions.

FACT 3: It has been the experience of many dentists that some insurance companies tell their insured that “fees are above the usual and customary fees”, rather than saying “our benefits are low”. Remember, you get back only what you and your employer put into your insurance coverage less the profits of the insurance company.

FACT 4: Each plan utilized in our office has different percentages, deductibles, maximums, procedures covered, and varying fees that the plan will allow. We will do our very best to make as close a calculation as possible of what your insurance plan will cover. However, this calculation is only an estimate, there may be variances of which you as the patient are financially responsible for.

FACT 5: Many routine dental services are NOT covered by insurance carriers. Our recommendations are made based on your needs and not what you insurance may or may not cover.

We want you to be comfortable in dealing with these matters therefore we encourage you to ask questions regarding our office policies, services, and/or fees. As a courtesy we will complete and file insurance forms on your behalf. We will do all we can to assure you of your maximum benefits.

If you have questions regarding the details of your insurance plan, please contact your insurance carrier as they are operating on your behalf.

Late Accounts

Unless payment arrangements have been made, we reserve the right to place all excessive past due balances with an independent service for collection. You will be responsible for outstanding balances as well as fees.

I authorize the release of all necessary information.

I have read this form and agree to be financially responsible for all fees regardless of insurance coverage.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.